Mental Health Eating Disorders Workshop
Summary notes of the Eating Disorder Workshop held on 17th November 2014 at 1.00pm at
Meeting Room L, The Innovation Centre, St Cross Business Park, Newport
Present
/ Apologies
Present,
Sue Lightfoot, Head of Commissioning, IOW CCG
Louise Doughty,Head of Mental Health & Programme of Care Lead, NHS England
Gareth Davies, Berkshire Healthcare NHS foundation Trust
Smith Mo, Acting Head of MH, LD and Community Partnerships, IOW NHS Trust
Fryer Beverley, Quality and Safety Lead, IOW NHS Trust
Dr Umama Khan, Consultant, IOW NHS Trust
Dr S Sulaiman, Consultant Psychiatrist.
Dr Bowers Alexis, Consultant Psychiatrist, IOW NHS Trust
Sellers David, Modern Matron, IOW NHS Trust
Cripps Stacey, Deputy Service Lead, IOW Trust
Karen Morgan, Head of Quality, IOW CCG
Keats Tracy, Adult Safeguarding, IOW CCG
Amanda Sellers, Commissioning Director Healthcare, Priory Group
Peter Smith, Service Line Director Acute, Addictions and Eating Disorders, Priory Group
Ben Marshall, Business Manager, Priory Group
Helen Figgins, Commissioning Manager, IOW CCG
Karen Kerley, Join IOW LA / CCG Project Manager
Sue Jones, Administrator, IOW CCG
Apologies,
Rachael Hayes, Head of Community Commissioning, IOW CCG
Dr Sarah Gladdish
Dr S Sulaiman, Consultant Psychiatrist
Dr Nadarasar Yoganathan, Consultant, IOW NHS Trust
NOTES BY:
Sue Jones (SJ) - Administrator
Item number
as per agenda
1.
Action Initial
Welcome, introductions and overview – Sue Lightfoot (IOW CCG)
Following the welcome and introductions SL gave an overview of the
plan of the afternoon workshop, including;
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National Picture – including number of people with Eating
Disorders and the critical window for intervention for people.
Reason for the meeting – to agree what the island needs to do
and what does good look like.
A need for robust strategies and pathways for eating disorders
Commissioning of integrated pathway with is person centred
pathway, and includes support for carers, family and friends.
HF informed the group of statistics of eating disorders including;
 91% of eating disorders are female, 9% male.
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Average ages,
o Female 15 years old.
o Male 13 years old.
People admitted for an eating disorder are more likely to stay in
hospital for a longer period of time with 32% staying longer than a
month compared to 1% of all FAEs.
Average length of stay;
o 136 days – Adult.
o 137 days – Child.
Presentation attached
Eating Disorder 2014
Presentation.pptx
2.
Review of recent cases – needs gap analysis – Dr Umama Khan & Bev
Fryer (IOW NHS Trust)
BF and UK gave synopses of events around 3 recent eating disorder cases as
an insight into what is help is available locally and what services are required.
Issues highlighted;
 Education of ward staff – lack of understanding of the condition and
care required.
 Medical staff unhappy to take care of the patient.
 No care team, with expert knowledge.
 No clear understanding who take the lead on eating disorder cases.
 No Eating disorder specialist psychiatrist on the island.
 Lack of co-ordination - no guidance around when or who to alert.
 Gaps in psychological therapies.
 No MARSIPAN workforce - MARSIPAN: Management of Really Sick
Patients with Anorexia Nervosa.
 Cases not being picked up early enough by primary care.
Highlighted requirements
 Implementations of Marzipan Workforce across whole Trust for up
both step up and step down; MARSIPAN is now a requirement rather
than guidance.
 Reduction of the gap in psychological therapy services.
 Raise public awareness of the condition through Public Health, early
signs which family and friends may observe and where to go for help
and advice.
 Look at options of using the GP screening tool to help with earlier
diagnosis and intervention.
Priority Action: to include implementation of MARSIPAN
 Conversation between Alan Sherwood and Mark Pugh to discuss
timelines
 Development discussions to include Commissioners from both Acute
and Mental Health and representation from Trust from both Mental
Health and Acute, with involvement from external Senior
Clinicians.
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3.
NHS England – Louise Doughty (NHS England) & Gareth Davies (Case
Manager NHS England)
- Specialist ED Service specifications
- Gate keeping
LD and GD informed the group that they are contacted in relation to a
case they help to match the patient to a suitable bed, which includes
clinician to clinician conversations.
GD highlighted that cases received by Specialist from the island tend to be
received late, it’s better to build a picture of the case and if the case is
already is already in specialist commissioning’s radar decline can be
monitored as there is always competition for bed allocation. NHS England
through specialist commissioning share bed numbers for CAMHS every
Friday.
Action: GD to share location map of Eating Disorder Units
4.
What does good look like?
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Early intervention and support– less inappropriate placements.
MARSIPAN to be included in the Commissioning Intentions.
Steering group to identify MARSIPAN members who will be
responsible for ensuring safe and effective management of very sick
patients with an eating disorder who are admitted to the General
acute hospital due to physical health compromised by eating disorder.
MARSIPAN group to include;
Lead Psychiatrist,
o Lead Physician - Gastroenterology
o Dietician
o Specialist Eating Disorders Nurse
Eating Disorder Team.
Staff training on Eating Disorders.
Timeline – joint agreement from IOW NHS Trust, Clinical
Commissioning Group and Local Authority (Social Care).
A clear pathway developed which follows the patient and includes
family support.
A good Eating Disorder pathway needs joined up planning, main
stakeholders to form steering group to include;
o Adult Psychiatrist
o Child and Adolescent Psychiatrist
o Acute Hospital Consultant Physician ( Gastroenterologist)
o Physiotherapist
o Dietician
o Specialist Commissioning representation
o Psychological Therapies representative
o Systemic Psychotherapist.
Discussions were had around the need to create a robust business case and
realignment of funding and resources.
5.
Development of Pathway
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An analysis of need to identify the current number of people with an
eating disorder on GP caseloads ( unknown to MH Services), Child and
Adolescent MH caseload, Community Mental Health teams,
Psychological Therapies Team case load and those currently in local
psychiatric/ acute general hospital or in Specialist placements via NHS
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England.
Consideration should be given to develop a pathway that spans child
and adolescent services, supports smooth transition between services
(child/ adolescent and adult) and has clear step up and step down
procedures.
When a patient is identified as potentially needing or admitted in
crisis to a general acute ward MARSIPAN to be alerted.
Step down from specialist services to local commissioning teams and
local providers should be planned in advance where possible. If
additional or intensive support is required this can be requested by
the NHS provider lead professional submitting a pro-forma expressing
clinical reason for additional support which will aim to reduce the risk
of relapse or readmission.
An audit of existing skills in the workplace of practitioners competent
to assess and work with patients with an eating disorder will
determine the need for training and work force development. Identify
gaps in skill and plan for adequately trained and competent workforce
to meet local need
Public Health to contribute to increasing awareness of eating
disorders and promotion of self-esteem and healthy lifestyle choices
to work with school nurses at community level.
MARSIPAN members to agree parameters, protocols and policies for
the management of very unwell patients. MARSIPAN group will
develop clear pathway of clinical responsibilities and transfer of care
procedures.
Development of a virtual ED multi-disciplinary team to;
o Assess
o Advise and support professionals working with patients with
an eating disorder
o Co-ordinate and manage step up / step down of patients with
an eating disorder.
Marispan - Executive Summary and Recommendations http://www.rcpsych.ac.uk/files/pdfversion/CR162.pdf
The MARSIPAN working group arose out of concerns that a number of
patients with severe anorexia nervosa were being admitted to general
medical units and sometimes deteriorating and dying on those units because
of psychiatric problems, such as non-adherence to nutritional treatment,
and medical complications, such as re-feeding syndrome. Sometimes
overzealous application of National Institute for Health and Clinical Excellence
(NICE) guidelines led to death from underfeeding syndrome. In the present
guidelines, which emerged from mostly online discussions of the MARSIPAN
group, we have provided:
- Advice on physical assessment
- Advice to the primary care team and criteria for admission to both
medical units and specialist eating disorder units as well as nonspecialist psychiatric units, and criteria for transfer between those
services.
- Advice on the required members of the in-patient medical tea
medical, nutritional and psychiatric management of patients with
severe anorexia nervosa in medical units, including the appropriate
use of mental health legislation.
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Advice for commissioners on required services for this group of very ill
patients.
Our group became aware of 12 cases of young people with severe
anorexia nervosa who had died on medical units owing to re-feeding
syndrome, underfeeding syndrome and other complications of
anorexia nervosa and its treatment.
We believe that the problem is widespread but as yet not quantified.
However, we hope that implementation of these guidelines
will help to reduce the number of avoidable deaths of patients with severe
Anorexia Nervosa.
Marizpan Guidance
Recommendations
1. Medical and psychiatric ward staff need to be aware that adult patients
with anorexia nervosa being admitted to a medical ward are often at high
risk.
2. Physical risk assessment in these patients should include body mass index
(BMI), physical examination, including muscle power, blood tests and
electrocardiography (ECG).
3. Most adults with severe anorexia nervosa should be treated on specialist
eating disorder units (SEDUs).
4. 4 Criteria for medical admission are the need for treatments (such as
intravenous infusion) not available on a psychiatric ward or the
unavailability of a suitable SEDU bed.
5. The role of the primary care team is to monitor such patients and refer
them early.
6. The in-patient medical team should be supported by a senior psychiatrist,
preferably an eating disorders psychiatrist. If an eating disorders
psychiatrist is unavailable, support should come from a liaison or adult
general psychiatrist.
7. The in-patient medical team should contain a physician and a dietician
with specialist knowledge in eating disorders, preferably within a nutrition
support team, and have ready access to advice from an eating disorders
psychiatrist.
8. The key tasks of the in-patient medical team are to:
- Safely re-feed the patient.
- Avoid re-feeding syndrome caused by too rapid re-feeding.
- Avoid underfeeding syndrome caused by too cautious rates of
refeeding.
- Manage, with the help of psychiatric staff, the behavioural problems
common in patients with anorexia nervosa, such as sabotaging
nutrition.
- Occasionally to treat patients under compulsion (using Section 3 of
the Mental Health Act), with the support of psychiatric staff manage
family concerns arrange transfer to a SEDU without delay, as soon as
the patient can be managed safely there.
9. Health commissioners should: be aware of the usually inadequate local
provision for MARSIPAN patients ensure that robust plans are in place
including adequately trained and resourced medical, nursing and dietetic
staff on the acute services and specialist eating disorder staff in mental
health wards.
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6. Draft diagram of the eating disorder pathway
This diagram reflects the ongoing support from family and community
7. Follow up event to be held in approximately 6months
Present,
Sue Lightfoot, Head of Commissioning, IOW CCG
Louise Doughty,Head of Mental Health & Programme of Care Lead, NHS
England
Gareth Davies, Berkshire Healthcare NHS foundation Trust
Smith Mo, Acting Head of MH, LD and Community Partnerships,
IOW NHS Trust
Fryer Beverley, Quality and Safety Lead, IOW NHS Trust
Dr Umama Khan, Consultant, IOW NHS Trust
Dr S Sulaiman, Consultant Psychiatrist.
Dr Bowers Alexis, Consultant Psychiatrist, IOW NHS Trust
Sellers David, Modern Matron, IOW NHS Trust
Cripps Stacey, Deputy Service Lead, IOW Trust
Karen Morgan, Head of Quality, IOW CCG
Keats Tracy, Adult Safeguarding, IOW CCG
Amanda Sellers, Commissioning Director Healthcare, Priory Group
Peter Smith, Service Line Director Acute, Addictions and Eating
Disorders, Priory Group
Ben Marshall, Business Manager, Priory Group
Helen Figgins, Commissioning Manager, IOW CCG
Karen Kerley, Join IOW LA / CCG Project Manager
Sue Jones, Administrator, IOW CCG
Apologies,
Rachael Hayes, Head of
Community Commissioning,
IOW CCG
Dr Sarah Gladdish
Dr S Sulaiman, Consultant
Psychiatrist
Dr Nadarasar Yoganathan,
Consultant, IOW NHS Trust
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